A mental health nurse is caring for a newly admitted client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

Instruct the client on relaxation techniques for use when anxiety level increases.

Discuss many alternative coping strategies with the client.

Identify precipitating factors for ritualistic behaviors.

Provide a highly structured activity schedule for the client.

Answer and Explanation

The Correct Answer is C

Choice A rationale: Instructing the client on relaxation techniques for use when anxiety level increases is a beneficial intervention for a client with OCD. However, it is not the first action the nurse should take. The nurse needs to understand the client’s condition, including the triggers for their ritualistic behaviors, before they can effectively guide the client in managing their anxiety.

Choice B rationale: Discussing many alternative coping strategies with the client is an important part of OCD management. However, this should come after understanding the client’s condition and the triggers for their ritualistic behaviors. Without this understanding, the coping strategies suggested may not be effective or relevant.

Choice C rationale: Identifying precipitating factors for ritualistic behaviors is the first action the nurse should take. Understanding what triggers the client’s OCD behaviors is crucial in developing an effective care plan. This understanding allows the nurse to work with the client to develop strategies to manage their triggers and reduce the frequency and intensity of their OCD behaviors.

Choice D rationale: Providing a highly structured activity schedule for the client can be helpful in managing OCD. However, this should not be the first action. The nurse needs to first understand the client’s condition, including the triggers for their ritualistic behaviors. This understanding will allow the nurse to develop a schedule that takes into account the client’s triggers and incorporates effective coping strategies.

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Correct Answer is B

Explanation

The correct answer is choice b. Moderate.

Choice A rationale: Severe anxiety is characterized by a significant reduction in the ability to perceive and process information. The individual may experience intense physical symptoms such as dizziness, hyperventilation, and a sense of impending doom. The client’s ability to focus is greatly diminished, and they may have difficulty functioning.

Choice B rationale: Moderate anxiety involves a heightened sense of awareness and a narrowing of the perceptual field. The individual may experience physical symptoms such as increased heart rate, sweating, and muscle tension. They can still focus and problem-solve but may need assistance. The client’s symptoms of chest pain, headache, and shortness of breath, along with their emotional distress, align with moderate anxiety.

Choice C rationale: Mild anxiety is associated with a slight increase in alertness and perception. The individual may feel restless and have minor physical symptoms like slight muscle tension. They can still function effectively and use coping mechanisms to manage their anxiety.

Choice D rationale: Panic level anxiety is the most severe form and involves a complete disruption of the ability to function. The individual may experience extreme physical symptoms such as chest pain, palpitations, and a sense of losing control. They may be unable to communicate effectively or respond to their environment.

Each level of anxiety presents differently, and understanding these differences helps in providing appropriate care and interventions.

A. Dissociation B. Regression C. Introjection D. Repression.

Correct Answer is B

Explanation

Choice A rationale: Dissociation is a defense mechanism where a person disconnects from reality, memory, identity, or perception. It is often a response to trauma and can result in a detachment from emotional and physical experiences. The client’s behavior does not indicate a disconnection from reality or self.

Choice B rationale: Regression is a defense mechanism where an individual reverts to an earlier stage of development in response to stress or anxiety. In this case, the client’s behavior of wanting someone to take care of them can be seen as a regression to a childlike state of dependency, which is a common response to overwhelming stress or anxiety.

Choice C rationale: Introjection is a defense mechanism where a person internalizes the ideas or voices of other people- often authority figures. This is not evident in the client’s behavior.

Choice D rationale: Repression is a defense mechanism where a person unconsciously blocks out distressing thoughts or feelings. In this scenario, the client is expressing their feelings of stress rather than repressing them.

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A mental health nurse is caring for a newly admitted client with obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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